Dr Dale. BMY1995;311:427-30. Primary care in the accident and emergency department: II. comparison ofgeneral practitioners and hospital doctors. Jeremy Dale, Judith ... senior house officers, registrars, and general prac- titioners in an ...
Primary care in the accident and emergency department: II. comparison ofgeneral practitioners and hospital doctors Jeremy Dale, Judith Green, Fiona Reid, Edward Glucksman, Roger Higgs
Departments of General Practice and Primary Care and Accident and Emergency Medicine, King's College School of Medicine and Dentistry and King's College Hospital, London SE5 9PJ Jeremy Dale, senior lecturer in prmary care Judith Green, research officer Department ofGeneral Practice and Primary Care, King's College School of Medicine and Dentistry, London SE5 9PJ Roger Higgs, professor Department of Public Health, King's College School ofMedicine and Dentistry Fiona Reid, statistician
Department ofAccident and Emergency Medicine, King's College Hospital, London SE5 9RS Edward Glucksman, consultant
Correspondence to: Dr Dale. BMY 1995;311:427-30
BMJ voLuME311
the effect of general practitioners treating patients Abstract Objective-To compare the process and outcome identified by nurse triage as presenting with primary of "primary care" consultations undertaken by care problems. In this paper, the impact on the process senior house officers, registrars, and general prac- of care is considered; a subsequent paper will describe titioners in an accident and emergency department. the impact on clinical outcome and patient satisfaction. Design-Prospective, controlled intervention study. Setting-A busy, inner city accident and emer- Method The study was carried out in the accident and gency department in south London. Subjects-Patients treated during a stratified emergency department at King's College Hospital, random sample of 419 three hour sessions between London, between 1 June 1989 and 31 May 1990. Bank June 1989 and May 1990 assessed at nurse triage as holidays and the first two weeks of August and presenting with problems that could be treated in a February (when accident and emergency staff change) primary care setting. 1702 of these patients were were excluded. A total of 27 senior house officers, three treated by sessionally employed local general prac- registrars, and one senior registrar were employed in titioners, 2382 by senior house officers, and 557 by the department during this period, and all were included in the study. registrars. Vocationally trained local general practitioners were Main outcome measures-Process variables: labrecruited to work "primary care" sessions in the and investigations, prescriporatory radiographic tions, and referrals; outcome variables: results of department. Preference was given, firstly to those who had recently completed training (that is, general investigations. Results-Primary care consultations made by practitioners registered for similar numbers of years to accident and emergency medical staff resulted in the accident and emergency doctors) and, secondly, greater utilisation of investigative, outpatient, and to those with flexible hours of availability. Eleven specialist services than those made by general general practitioners applied, and six were appointed; practitioners. For example, the odds ratios for two left during the study and were replaced. They patients receiving radiography were 2-78 (95% received honorary health authority contracts and so confidence interval 2-32 to 3.34) for senior house had access to the full range of hospital services. Each officer v general practitioner consultations and 2*37 was employed to work one or two three hour primary (1.84 to 3.06) for registrars v general practitioners. care sessions a week. A random sample of sessions stratified by time of day For referral to hospital specialist on call teams or outpatient departments v discharge to the com- and day of week was determined by using a table of munity the odds ratios were 2-88 (2.39 to 3.47) for random numbers. General practitioners and accident senior house officers v general practitioners and 2 57 and emergency medical staff were considered as two (1*98 to 3.35) for registrars v general practitioners. groups, and each group was allocated two or three Conclusion-Employing general practitioners in weekday sessions running from 1000 to 1300 and 1400 accident and emergency departments to manage to 1700, one weekday evening session from 1800 to patients with primary care needs seems to result in 2100, and one weekend daytime sessions for each week reduced rates of investigations, prescriptions, and during the study period. Hence, 8-10 sessions were referrals. This suggests important benefits in terms sampled each week for a total of 48 weeks. The sample of resource utilisation, but the impact on patient of sessions allocated to accident and emergency staff outcome and satisfaction needs to be considered was the same as those described in the accompanying paper.' Throughout the study period weekly rosters further. stipulated a named doctor with responsibility for primary care patients for every three hour session Introduction between 1000 and 2100. Neither the general pracAs reported in the accompanying paper, nurse triage titioners nor the accident and emergency doctors or assessment in the accident and emergency department nurses were informed about the study objectives can be modified to include classification of patients' or whether any particular session was part of the study presentations into "primary care" and "accident and sample. The criteria and method used to assess patients at emergency" categories.' At King's College Hospital this resulted in 41% of new attenders being classified as nurse triage have been described.' The triage system presenting with primary care problems suitable for included the allocation of patients into primary care management by a general practitioner.' However, 10% and accident and emergency categories and operated of primary care patients were referred to on call around the clock to ensure consistency of practice. The specialist teams and a further 9% were referred to the patient sample consisted of all those who were assessed fracture clinic or advised to return to the accident and as presenting with new primary care needs and who were treated during the selected sessions. Patients were emergency department for follow up. The implementation of this modified system of unaware of their triage status or the grade and specialty triage provided an opportunity for undertaking a of their doctor. Occasionally, such as when the departprospective, controlled intervention study of the ment was exceptionally busy, the triage status of relation between training and experience of the con- patients was not recorded, and in such instances sulting doctor and the consultation process and out- patients were excluded from the sample. This was come. The purpose of the study was to explore unlikely to happen when general practitioners were
12AUGUST1995
427
present, since their work depended on being provided Results with patients assessed by triage as presenting with The final sample consisted of 4641 primary care primary care needs. patients seen during 419 sessions, of which 215 had Although the intention was that all primary care been allocated to general practitioners and 204 to patients would be treated by the allocated doctor, this accident and emergency staff. A total of 1702 patients did not always occur. Firstly, at times when the were seen by general practitioners, 2382 by senior primary care workload was excessive, other doctors house officers, and 557 by registrars or the senior were directed by the nurse performing triage to treat registrar (treated in the analysis as a single group and primary care patients to prevent unacceptably long hereafter described as registrars). This distribution of waiting periods from occurring; secondly, registrars in patients reflected the extent to which accident and particular were often interrupted from completing emergency staff provided cover to the allocated doctor primary care sessions by departmental circumstances (both general practitioners and other accident and (such as responding to patients with urgent or life emergency staff) during sessions when the primary threatening needs or providing advice or supervision to care workload was particularly busy. (The number senior house officers). Hence patients were sometimes of patients seen by accident and emergency staff is attended by a non-allocated doctor, both during larger than that described in the accompanying paper' sessions originally allocated to a general practitioner because that study was not concerned with any conand during those allocated to another member of sultations that occurred during sessions allocated to accident and emergency staff. Since this breakdown of general practitioners.) randomisation was not always clearly documented, Not all records were complete; percentages given data for all recorded primary care consultations below refer to proportions of patients for whom occurring during the selected sessions were included data were retrieved. Table I gives characteristics in the sample, and data on patients were regrouped of the patients included in the sample, and table II according to the type of doctor actually seen. The shows the duration, previous care, and diagnoses loss of randomisation was allowed for by including of the problems presented. Table III shows the confounding factors in the analysis ofthe data. numbers of patients receiving investigations, presTo control the environment in which consultations criptions and referrals. The association between took place, a consulting room was designated and the doctor seen (general practitioner, senior house equipped for primary care consultations, and the officer, or registrar) and the main consultation process doctor assigned for primary care was encouraged to use variables was investigated by X2 analysis (table IV). it. Throughout the study period, all doctors using the All the process variables showed a significant associprimary care consulting room were asked to complete ation with the type of doctor seen, with the largest a consultation record form for each patient seen. effect sizes being for radiographic investigations This form facilitated data collection through ensur- and for referral after discharge. General practitioners ing that sociodemographic details, investigations, treatments, and referrals were recorded. It was not TABLE II-Duration, previous primary care, and diagnoses of possible to arrange for doctors treating patients in problems presented by primary care attenders at accident and emerother parts of the department to use this form. Doctors gency department remained blind to how data from these forms would be No (%/6) of patients
analysed.
PROCESS DATA
TABLE I-Characteristics of
primary care attenders included in sample No (%) of
patients
Age in years (n=4641): 0-5 6-16 17-20 21-25 26-30 31-50 51-60 >60 Social class (n= 1637): I II III Non-manual III Manual IV v
416 (9-0) 497 (10-7) 426 (9 2) 839 (18-1) 666 (14-4) 1076 (23-2) 312 (6-7) 409 (8 8)
33(20)
Unemployed
293 (17-9) 313 (19 1) 377 (23 0) 174 (10-6) 135 (8 2) 312 (19-1)
Sex (n=4627): Female Male
2192 (47 4) 2435 (52 6)
428
Primary care patients treated during sampled sessions were identified from the accident and emergency register and data were obtained from records and consultation record forms. Explanatory variables included the consulting doctor; patient's age, sex, occupational class, postcode, general practitioner, diagnosis (coded using the Royal College of General Practitioners' classification system2 up to the fifth digit, and then recoded according to chapter headings), and previous care given for the presenting problem. Process variables included the doctor's use of radiology, haematology, chemical pathology, and microbiology investigations; items prescribed (for patients not referred to on call teams); and referral and discharge decisions made by the doctor. Data on the results of investigations were obtained from laboratory and radiology reports. ANALYSIS
Data were analysed using the spss-x and BMDP statistical packages. Statistical analyses consisted of the Kruskal-Wallis test to compare the distribution of continuous variables between groups; X2 tests to investigate associations between pairs of categorical variables; and log-linear model analysis to estimate associations between more than two categorical variables. The best fitting log-linear models were found by first fitting all models of uniform order and then removing terms from the least well fitting model by backwards elimination.3 The goodness of fit of log-linear models was tested by using the likelihood ratio X2 statistic, G.2 A 1% level of significance was used for exploratory tests and 5% for log-linear modelling.
Duration of problem (n=4320): < 6 Hours 6-24 Hours 1-7 Days
662 (15-3) 969 (22 4) 1685 (39 0) 1004 (23 2)
> 7 Days
Previous primary care contact (n=3623): General practitioner Other None Diagnosis (n=4641): Infectious and parasitic diseases Endocrine and metabolic diseases Mental disorders Diseases of nervous system Diseases of eye Diseases of ear Cardiovascular and peripheral vascular diseases Respiratory system diseases Digestive system diseases Genitourinary system diseases Complications of pregnancy, childbirth, contraception Diseases of skin and subcutaneous tissue Diseases of musculoskeletal system Non-specific symptoms, signs Injury and poisoning Social, marital, and family problems
753 (20 8) 106 (2-9) 2764 (76 3)
229 (4 9) 42 (09) 93 (2.0) 46 (1-0) 145 (3-1) 127 (2 7) 67 (1-4) 302 (6 5) 273 (5 9) 254 (5-5) 89 (1-9) 289 (6 2) 634 (13-7) 326 (7 0) 2061 (44-4) 48 (1-0)
TABLE six-Investigations, prescriptions, and referrals TABLE, III-Investigations, prescriptions, and referrals received by, received
patients
No (%) of patients
Radiography (n=4606) Haematology (n=4624) Chemical pathology (n=4621) Microbiology (n=4618) Electrocardiography (n=4620) Prescription (one or more items) (n=4242*) Referral (n=4566): Community or general practice On call specialist team Outpatient clinic Retum to accident and emergency
966 (21-0) 125 (2 7) 88 (19) 143 (3-1) 92 (2 0) 1800 (42 4) 3676 (80 5) 376 (8 2) 289 (6 3) 225 (4-9)
*Excludes patients referred to on call teams.
BMJ VOLUME 311
12AUGUST1995
TABLE iv-Type of doctor seen by patients receiving investigations, prescriptions, and referrals. Values are numbers (percentages) Type of doctor seen General Senior house practitioner officer (n= 1702) (n=2382)
Radiography Haematology Chemical pathology Microbiology Electrocardiography Prescription* Referral to: Community or general practice On call specialist team Outpatient clinic Accident and emergency
Registrar (n=557)
X2 (df)
P value
207 (12-2) 14 (0 8) 10 (0 6) 35 (2-1) 21 (1-2) 640 (39 7)
619 (26-2) 106 (4 5) 71 (3 0) 99 (4-2) 64 (2 7) 921 (43 6)
140 (25.4) 5 (0 9) 7 (1-3) 9 (1-6) 7 (1-3) 239 (46 5)
123-7 (2) 57-9 (2) 32-2 (2) 19-4 (2)
12-6 (2) 9 7 (2)
